Oftentimes, an inpatient healthcare facility is reimbursed for treatment of patients based on a prospective payment system. As healthcare costs began to escalate, in 1983, the retrospective payment system for the Medicare program was replaced by a prospective payment system. The prospective payment system pays for acute hospital care based on the expected costs, rather than accrued charges.
Each patient discharged from a hospital setting is categorized into a billing group called a Diagnosis Related Group (DRG). The International Classification of Diseases, Ninth Revision, and Clinical Modifications (ICD-9-CM) is used to implement the DRG prospective payment system. ICD-9-CM is a diagnostic dictionary allowing diseases, symptoms, health problems and procedures to be classified and coded. The coded data elements are utilized to determine the DRG for a patient. The inpatient facility is reimbursed a predetermined amount for all services, no matter the length of stay or amount of resources used by the patient. Thus, a given inpatient facility may be paid the same for a patient with congestive heart failure who has had an inpatient stay of three days and a patient with congestive heart failure who has stayed for five days consuming more resources.
Current systems do not determine the predicted length of stay for a patient when the patient is admitted or during the patient's stay. The systems also do not display the current length of stay for the patient along with a predicted length of stay. As such, caregivers and administrators cannot easily view which patients are nearing discharge or determine which patients may require an extended stay for which utilization review is needed based on a predicted length of stay.